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ChummyAdapter1

Information about excision/punch grafting

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Hello everyone,

I am a longtime lurker of this forum and I just had a consultation with a plastic surgeon.  He gave me a ton of good information about excision for acne scars, so I thought I would share.  I have moderate boxcar and icepick scarring on my cheeks from acne when I was 12-17.  The acne didn't really bother me, but I hate how the scars look so I have been trying to fix them for the past year.  I have had 2 CO2 lasers and 2 subcisions, and I would estimate about 20-30% improvement.  I was watching a youtube video from Dr. Nassif (He's the doctor from the TV show botched) and he briefly talked about acne scars.  He said that they're hard to treat (we all already know this XD) and in his practice he either does excision or subcision depending on whether the person would prefer a slight depression or a flat linear scar.  I personally would prefer a flat linear scar, so I began looking into plastic surgeons for excision.  I saw my 2nd doctor today and I'm going to summarize everything he told me because he has a long history in facial reconstruction and plastic surgery.  I know a lot of people are scared of excision and I myself have read many posts on here about people who were unhappy with their excision, however he explained to me why some people get bad results.

1.  He said never go to a dermatologist for an excision because most dermatologists have minimal surgery experience compared to other fields of medicine.  I know what he said was true because my sister is in medical school and she said everyone who chooses to specialize in dermatology is squeamish and hates blood LOL.
2. He said going to a plastic surgeon is necessary to fix scars because they are the only branch of medicine that cares about aesthetics and the first things they learn involve scar tissue, i.e. a brain surgeon whose saving your life won't care if he leaves behind a scar.
3.  I asked him about punch excision and he said he does scapel excisions because the human body is not designed to heal tissue that is punched out.  The human body is designed to heal cuts and lacerations rather than large portions of skin being punched out to the fat which is why many punch procedures fail.
4. He also said many doctors try to treat too many scars at once.  The theory behind excisions is that once the scar is punched out, the healthy skin will grow and the scar should become much smaller.  However if too many scars that are close together are punched out at once, the scar tissue will cluster together and form a wider and possibly atrophic scar.
5.  Treating scars when you're younger is much better and I could possibly not even have a scar after excision if I'm lucky after a few years (fingers crossed XD)
6.  He also said I'm very lucky my scars are only on my cheeks because temple and forehead scarring is nearly impossible to deal with in his experience because of lack of fat and proximity to nerves.


He showed me a few before and after pictures of scar revision, but he did not have any photos of acne scar revisions.  He did have a photo of a girl who had oil burns on her face with extremely deep pock marks, and her results were amazing as she only had a few lines on her face and they only looked like dimples.  So I made a plan with him to excise my scars slowly over a period of three months, and I will be updating you guys and hopefully be posting good pictures XD.  Wish me luck!
 

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2 hours ago, ChummyAdapter1 said:

I personally would prefer a flat linear scar, so I began looking into plastic surgeons for excision.  I saw my 2nd doctor today and I'm going to summarize everything he told me because he has a long history in facial reconstruction and plastic surgery.  I know a lot of people are scared of excision and I myself have read many posts on here about people who were unhappy with their excision...


Since you didn't provide any pic, it's hard to say. First, how deep and how wide is (or are) your scar(s)? More importantly, how many scars are you treating? It sounds like you're treating only one scar. In that case, no big deal. But most of us have numerous scars and excision is just not feasible.

However, excision is one of many treatment options, and I don't think anyone thinks bad about it (or do they? I dunno). If I were treating only one sar, excision would be the last one on my bucket list. I would just get it filled with Bellafill. No blood, no mess. Quick and clean. We all love quickies, don't we?
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Hey Sirius thanks for the reply.  I plan to post pics soon but I'm super swamped right now because finals are coming up.  But I have scarring all over my cheek and I would say some are superficial and some are much deeper.  I wish I only had one scar LOL I wouldn't be here.   IMO Bellafill or silicon would be my last resort because of all the risks involved, even after deep phenol peels and excision.  Sometimes the filler becomes inflamed and forms giant nodules that are impossible to remove because they encase the facial nerves and blood vessels.  I know this is pretty rare but it still scares me.  Not to mention all the other problems like aging, migration, etc.  But I didn't make this post for help I just wanted to give information about a very underrated treatment.  If you take this persons results for example:
https://www.acne.org/messageboard/gallery/album/10201-scar-excision/

He has better results than the golden examples on this forum like MrMatt.  If you search the forum for excision most people are trying to persuade people not to do it or only recommending punch excision.  BeautifulAmbitions guide only mentions punch excision and says it has a high outcome of poor results which I feel in the hands of a good plastic surgeon is not true for scapel excision because they constantly perform it.  On the other hand, Dermatologists training involves diseases like skin cancer, psoriasis, eczema, etc and if there is any mention of acne scarring it just involves lasers.  I just want people to know that this can be a great alternative and worse comes to worse your left with a different scar which is already at risk from chemical peels, lasers, and subcision.  I've seen some posters that have had 5+ subcisions and other hoping that they will no longer be indented but the reality is you will always have some sort of indent with microneedling, subcision, and chemical peels.  For many scar suffers the worst part of scarring is the atrophy (Including myself), and this is a great way to trade an indented scar for a flat line that can easily be covered by makeup or even lasered off possibly.
 

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I think excision also depends on the location. Areas where there is much facial movement can be risky, as the sutures holding the scar together might potentially come loose. From what I've read, the best places to excise are areas that don't move around much.

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Good point Raster I think that is very true.  I read some posts online about people taping their faces to ensure that they won't have scars after excision...might try that.  I would easily trade not smiling for two weeks while the stitches are in to ensure that my scarring does not get worse.

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I think excisions should only be reserved for scars that are so thickened or jagged / sharp that no amount of fillers or resurfacing would make it look acceptable.  In those cases, it might be okay to excise the skin that is damaged beyond the point of no return.  

The one thing that is always true with scar revision though is that the resulting incision will be LONGER than the scar.  That's because you must excise the skin in an elliptical shape so that the edges will meet without bunching up at the ends ( a dog ear deformity).   

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Wow... thought derms and plastics work together for the better good for the patient and not ego. Starting from the first thread-

1. Disagree. See video on laser and subcsion, rhinophyma... this dermatologist loves blood. Enough to be squeamish, or would Nassif like a O negative blood transfusion for every one of his ops???. Two types of dermatologist, medical, and procedural. The later operates, lasers and does stuff like below. 


2.Plastics surgeons operate... when they operate they give scars. Procedural dermatologist REPAIR scars from plastics. This is called team work, plastics work in a different plane than dermatologists. Dermatologist do not usually go beyond the fat layer, its called 'skin deep'. Team work gives best patient outcomes. 

3. Agree 100%, Punch excision ....not great, punch elevation .... tricky. But looking at the literature, I do agree with this dude.... scalpel over punch in 99% of cases. Elevation is another topic. 

4. Agree 100%... too many plastics- derms go for as many scars with add on procedures. Not good for healing. Agree with this statement. 

5. Agree 100%- early scars remodel better. This is a general statement. If you are younger, chances are you can generate more neo-collagenasis. There are however exceptions to this rule. Even at 88 years old using old fashion CO2 Fraxel and surgery for ' Squeamish dermatologist with minimal surgical experience',  there are always exceptions. 



6.Agree on forehead scar. 1. 5 mm between skin and bone. It is a hard area to work on, but its possible. Need multiple treatment over time. Temple scars, super easy. Will have to challenge this Plastics on this one. Temple area, one has to watch the temporal nerve and the temporal artery, but if one is in the deep plane or the very superficial plane, its one of the easiest areas to treat. Plastics should know their anatomy backwards!!!!!!  If scars are depressed, deep filler LIFTS sunken scars, if scars are superficial, treat them with superficial subcsion . Plastics are infinitely better than dermatolgosist at breast implants, tummy tucks and butt lifts, but working under the skin with precise subcision, well... you be the judge. 

Its not about big Dr egos, its about getting the BEST possible outcome for patients. This may no be shared by others, but I think it is good practice that doctors work with each other to give the best possible results, and RESPECT their colleagues. That is good practice. Bottom line, see who you are comfortable with. 
 


 
 
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In US and Canada, there are dermatologic surgeons (not plastic surgeons), who in my opinion are the best to treat acne scars. In general, they dont charge as much as plastic surgeons and have more expertise then a dermatologist. Offcourse there are exceptions

Edited by keving100
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@Jaspa0411 I have covered this a few times... I think it's a outdated procedure for acne scars, few do it anymore on their menu of services. Sure one can do geometric plastic surgery type procedures. What a plastic surgeon does not tell you is they are experts at hiding scars in places you don't see. Kinda hard when your face will have scars all over it from acne scar excision right. Number one rule, surgery leaves a scar, find alternatives until nothing else works. Some of the most unhappy people on here have had surgery first, they were sold things that did not happen, or their body did not heal right. Sure it's it's a "little" scar or one or two this is a option. But few have that.   I have seen people straight up get a big line on their forehead when it was a little boxcar before. As we know there is lots of muscle / skin tension in this area and high movement, not a good spot. Ultimately people go off beauty shots aka pictures, and those are the best cases to do the sale. 
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I agree... Excisions are a last resort procedure.  It is too extreme and ends up being a total crapshoot most of the time.  If we were to look at different procedures on a spectrum, fillers and subcision would be on the safe end with excisions / dermabrasion / lasers on the other end in terms of risk.  

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@beautifulambition I agree with your insight and appreciate all the help you have contributed to the board.  The doctor made it clear to me that it is necessary to have healthy skin in between scars for an excision to be successful and as such I understand why someone who has more extensive scarring would not undergo it.  I have scars all over my cheeks but I do have healthy skin between my scars so I feel I would get good results from it.  The doctor also told me he doesn't do forehead or temple excisions because they have less fat than the rest of the face and the forehead carries most of the face's tension and usually ends up pulling stitches apart.  I don't know about most people but I would much rather have a linear scar that's flat than a pitted scar which is why I'm interested in excision.  I've seen numerous dermatologists and plastic surgeons over the last year and they made it clear that even after multiple lasers, subcisions, and microneedling procedures there will always be some sort of an indent.  As such I think it is necessary for more people to consider scapel excisions because most people with scarring that I have seen do have healthy skin between their scars.  For men a linear scar will look cool/edgy and for women it can be much easier to cover up.  Just my two cents :)

As an aside I remember a member posted a before and after picture of a man with skin cancer who had perfect skin, which is surprising considering the deep holes left in his face from having large amounts of cancer removed (much deeper than acne scars).  The member asked how it's possible for him to have perfect skin yet it is impossible to get rid of acne scars.  The reality is that most people with skin cancer end up going to reconstructive surgeons or plastic surgeons for excisions (Derms very rarely handle the reconstruction unless they specialize in Moh's surgery).  Edited by ChummyAdapter1
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I highly recommend Dermalmd blemish relief. It works fast even on those big, painful ones that are not ready to pop. I’ve tried natural products from those tier companies that didn’t work and I’ve tried other top brands that cost a lot of money. This serum works.

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Yes it leaves scar but nothing disgusting as a acne scar

What is the other treatment for lets say icepick

tca cross? It cant raise the scar perfectly as excision, also tca cross seems to start working after 2 or 3 session time consuming and gambling you dont know if it will work or no after every session.

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